Prenatal Opioid Use and NAS

Prenatal Opioid Use and Neonatal Abstinence Syndrome in the United States: Recommendations for Improvements in Prevention and Treatment

Abstract

Misuse and abuse of opioids, prescribed or otherwise, in the United States represents a massive public health concern. Although the U.S. represents only five percent of the world population, its residents account for approximately 99% of world hydrocodone use. Prenatal opioid use has intensified, increasing 5-fold from 2000 to 2009, with treatment for neonatal abstinence syndrome increasing 3-fold over the same interval. Neonatal abstinence syndrome (NAS) is associated with higher morbidity, protracted hospital stay and significantly increased neonatal healthcare expenditures. This paper addresses the systemic and individual barriers to effective healthcare use and access within the population of pregnant opioid users. Evidence-based recommendations to improve health outcomes include appropriate access to healthcare, family planning services and health insurance. Interventions to improve patient and provider knowledge as well as issues of stigma are recommended as well.

Introduction

Misuse and abuse of opioids, prescribed or otherwise, in the United States represents a massive and growing public health concern. Although the United States represents only five percent of the world population, its residents account for approximately 99% of world hydrocodone use (“A brief history of the prescription opioid epidemic,” 2016). In 2015, there were over 2.6 million Americans with opioid use disorder and more than 33,000 Americans died from overdoses involving opioids (Wen, Behrle, & Tsai, 2017).

Consistent with these developments, prenatal opioid use has intensified, increasing 5-fold from 2000 to 2009, with treatment for neonatal abstinence syndrome increasing 3-fold over the same interval (Meyer & Phillips, 2015). Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome in newborns that is indicated by symptoms demonstrating central nervous system hyperirritability and dysfunction of the autonomic nervous system, gastrointestinal tract, and respiratory system (Jones & Fielder, 2015). NAS-related withdrawal symptoms have been noted in 60% to 80% of neonates exposed in utero to heroin or methadone (Patrick et al., 2012). NAS is associated with higher morbidity, protracted hospital stay and significantly increased neonatal healthcare expenditures. In addition to NAS, illicit drug abuse during gestation corresponds to a substantial increase in risk for maternal complications such as placental abruption and neonatal complications such as preterm birth, stillbirth, and neonatal death (Black, 2016).

A 2011 report (Substance Abuse and Mental Health Services Administration) stated that in the United States, the rate of illicit drug use was 20.9% in pregnant women aged 15 to 17, 8.2% in pregnant women aged 18 to 25, and 2.2% in pregnant women aged 26 to 44. Within the population of drug-using women, unplanned pregnancies are common (Black, 2016). Approximately 90% of substance-abusing women are of reproductive age (Kuczkowski, 2007). Yet it is estimated that only about half of women with opioid and other substance use disorders use contraception (Terplan, Hand, Hutchinson, Salisbury-Afshar, & Heil, 2015). The volume of unplanned pregnancies within this group, as well as the health complications and higher costs of care associated with the ensuing births, highlights the importance of contraception among opioid-using individuals. States have a strong incentive diminish the prevalence of NAS, because coverage of related hospital expenses mostly fall to state Medicaid programs (Patrick et al, 2012). This paper will address the barriers to effective healthcare use and access in this cohort, and will make evidence-based recommendations to improve health outcomes based on current research.

Historical Context: The Opioid Epidemic and NAS

The current opioid epidemic should be considered with regard to both society’s past experiences with opioids and the current opioid epidemic. The contemporary opioid epidemic is not the first opioid epidemic and consequent rise of NAS, the United States has seen. A major opioid epidemic arose in the 1800s. Between 1840 and 1890, opioid consumption soared by 538% (Kolodny, 2015). While there were various origins to the epidemic, the chief cause was iatrogenic morphine addiction. Poor understanding and scarce cures for painful conditions led to the reliance on one of the few available tools for physicians. NAS in Western culture was first recognized in 1875 in Germany. The first cases described United States cases began appearing in 1892 (Jones & Fielder, 2015). The syndrome was first known as “congenital morphinism” and later as “infant addiction” or “congenital neonatal addiction”. At that time there was no recognized treatment regimen for withdrawal in neonates, resulting in variable treatment practices such as mothers blowing opium smoke in infants’ faces. Increased knowledge of bacteriology and public health diminished the prevalence of conditions usually treated with opium. The development of alternative pain medicines, more stringent prescription laws, and warnings about morphine in literature and periodicals also helped curb the addiction problem (Kolodny, 2015).
Prescribing of opioid pain medications began to rise steeply again following a 1995 campaign by the president of the American Pain Society, James Campbell, called “Pain is the Fifth Vital Sign”. Campbell stated that pain should be assessed aggressively and encouraged the prescription of opioids for chronic non-cancer pain (Campbell, 1996). Campbell’s 1995 Presidential address stated that opioids were being underused due to “misinformation about what addiction is and myths about liability for addiction in patients with pain” as well as “fear of regulatory reproach by government” (Campbell, 1996). Purdue Pharma provided financial backing to several organizations that in turn promoted more active pain identification and treatment, particularly usage of opioid pain relievers (Kolodny, 2015). One of these, a 1999 Joint Commission on Health Care initiative, drew attention to the undertreatment of pain (“A brief history of the prescription opioid epidemic,” 2016). The zero-to-ten numeric pain scale was standardized and promoted, and a number of studies found a low risk of addiction associated with opioid painkiller treatment. Unfortunately, these studies were poorly designed and overlooked several dangers inherent to this type of treatment. The startling inadequacy of many of the studies reporting a low risk of opioid addiction is explored at greater length by Juurlink and Dhalla (2012). Nevertheless, the American Pain Society and the American Academy of Pain Medicine released a joint statement recommending opioid use for chronic non-cancer pain. The statement downplayed the dangers of addiction, tolerance, opioid-induced respiratory depression, drug diversion, and drug abuse (“The use of opioids for the treatment of chronic pain,” 1997). The result of these developments was a rise in milligram per person use of prescription opioids, leading to the United States’ vastly disproportionate consumption of hydrocodone (“A brief history of the prescription opioid epidemic,” 2016).

Pain patients’ role in the epidemic may be greater than once believed. Most individuals who abuse opioids acquire them from sources other than their own prescriptions. However, for those reporting long-term use (200 to 365 days of use), data suggest that opioid pain relievers are most often acquired via prescription from physicians (Jones et al, 2014). While some studies suggest lower rates of addiction in individuals for whom opioids were prescribed, others demonstrate high rates of addiction in pain patients, and the precise rate is unclear (Compton, Boyle & Wargo, 2015). Data from the National Survey on Drug Use and Health (NSDUH) conducted yearly from 2002 through 2011, demonstrate a recent (12 months prior to interview) heroin incidence rate was 19 times higher among those who reported prior nonmedical pain reliever (NMPR) use than among those who did not (0.39 vs. 0.02 percent). In contrast, the recent NMPR incidence rate was almost twice as high among those who reported prior heroin use than who did not (2.8 vs. 1.6 percent) (Muhuri et al, 2013).

Although we have graduated from the “blow smoke in an infant’s face” stage of confronting these difficulties, one might hope we are in a similar Dark Age relative to the advances yet to come. The first opioid epidemic demonstrated that it was possible to halt the epidemic through gains in knowledge and education. A solution-oriented approach to the opioid epidemic, unplanned pregnancy in opioid users, and prenatal opioid use must bear in mind this lesson.

Determinants of Unplanned Pregnancy in Opioid Users

Unplanned pregnancy in opioid users is a strong indication of an unmet need for contraceptives in this group. Survey results from 946 pregnant opioid users entering substance abuse treatment in the United States indicated that 86% stated a history of at least one unplanned pregnancy (Heil et al, 2011). Individual knowledge and behavioral barriers, as well as system-level barriers, deter adequate access to contraception services in the opioid-abusing population. Regular intoxication, low socio-economic status, and inadequate access to health services contribute to healthcare disparities in this group. Other factors include mistaken beliefs that opioids will reliably harm fertility, misunderstandings regarding the safety of contraceptive methods, and trouble using conventional healthcare systems due to cost of care, mistrust of the healthcare establishment, or fear of losing child custody. Further, despite substantial evidence supporting the benefits of LARCs (long-acting reversible contraceptives), there is a general lag in both provider knowledge about these methods and in providers’ LARC insertion skills (Black, 2016).

Recommendations

The ideal way to confront unplanned pregnancy in United States opioid users and its associated health effects would be to extinguish the country’s opioid epidemic. This large task will require investments such as interventions targeting both providers’ prescribing behaviors and patients’ behaviors such as medication sharing and diversion. Innovations in alternative substance abuse treatment options and alternative pain medications are also important potential areas of development. However, as we await widespread and effective effort toward these improvements there is also obvious space to intervene on several different levels to decrease the volume of pregnancies in this group and minimize consequent detrimental health repercussions. We will discuss several possibilities for interventions and recommendations to ameliorate this problem.

Access to Healthcare, Health Insurance and Family Planning Services

Pregnant drug users often avoid seeking healthcare because they fear the response of the medical and legal communities (Curet & Hsi, 2002). Some of these fears and subsequent barriers to care may be alleviated through relaxed punishments for drug possession and increased efforts by law enforcement and health officials to divert drug abusers to Drug Treatment Court as opposed to incarceration.
In the United States, 78% of newborns with NAS and 60% of mothers with infants who have NAS are covered under Medicaid; these individuals often reside in zip codes within the lowest income quartile (Patrick et al, 2012). Births associated with NAS are often costly, with a 2009 mean hospital charge of $53,000; this amount is only rising as time passes (Patrick et al, 2012). Clearly Medicaid is a crucial resource for these patients. The current push in Congress to cut taxes is potentially the first step to cutting aid for these individuals to receive the care they need. The non-partisan Joint Committee on Taxation (2017) reports that the $1.4 trillion-dollar tax plan would produce about $400 billion dollars’ worth of growth, making the total net cost of the plan $1 trillion dollars, undermining the credibility of the White House’s claim that the plan would pay for itself. Speaker of the House of Representatives Paul Ryan stated during a radio interview on December 6, “We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit.” Ryan then added that Medicare and Medicaid were “the big drivers of our debt,” (Speaker of the house paul ryan on tax reform and more |ross kaminsky). Vulnerable populations such as low-income pregnant opioid users and children with NAS should not have their health care funding taken away to give high income individuals a tax cut. The plan to gut entitlements would have enormous and devastating consequences to persons with these health issues.

Further, funding for family planning services for people with low incomes must be preserved. For instance, Planned Parenthood is extremely important to individuals utilizing Medicaid, yet numerous states have attempted to exclude that organization from Medicaid coverage. The Congressional Budget Office estimates that preventing Medicaid coverage of these clinics on a nationwide scale would result in 390,000 women losing access to family-planning services and up to 650,000 women facing diminished access to preventive care services (Rosenbaum, 2017). Consistent and continued efforts by the Republican Party to undermine access to Planned Parenthood raise concerns about the already high rates of unintended pregnancy in the opioid-using population. Planned Parenthood provides preventive healthcare and contraception services to millions of low income individuals each year (Planned Parenthood, 2017). Research indicates that low socioeconomic status itself increases risk for unintended pregnancy (Iseyemi, 2017), and that provision of no-cost contraception results in decreased numbers of unintended pregnancies (Peipert, Madden, Allsworth & Secura, 2012). Although 62% of Americans support continued funding of Planned Parenthood (Bailey, 2017), Republican proposals such as the American Health Care Act of March 2017 (Cunningham, 2017) continue to target the organization. Although that bill was voted down in the Senate, it is reasonable to conclude Planned Parenthood faces continued threats to its funding, as do U.S. health insurance programs in general. From a public health perspective, this is potentially extremely dangerous, as the Congressional Budget Office report suggests that the bill would have left 15% of low-income and rural women “without services that help women avert pregnancy” (Congressional Budget Office, 2017). The implications for opioid-using women of reproductive age, many of whom also meet these distinctions (Meyer & Phillips, 2015), are horrifying. Public health professionals must continue to speak out against these bills as they arise, fight for continued funding of Planned Parenthood, and push for more comprehensive health insurance for all Americans.

Adequate Healthcare Access in Isolated Geographic Locations

While heroin abuse in the United States has historically been associated with cities, a recent study of heroin users showed that 75% resided in small urban or non-urban locations, in contrast to 25% in larger urban areas (Cicero, 2014). Rural residents have less access to health care in general compared with urban residents and individuals with substance use problems are less likely to have health insurance than those without these issues (Moody, Satterwhite & Bickel, 2017). These areas would benefit from innovations such as mobile units providing access to medication-assisted drug treatment and reproductive health services.

Integrated Health Care and Contraception Services with Substance Abuse Treatment

Women make up about 30%–40% of drug and alcohol treatment utilizers, and these rates are increasing (Black, 2016). Yet, these services do not generally address women’s sexual and reproductive health despite many deficiencies in the health of this population relative to the general population. Integrated health care that houses sexual and reproductive health together with drug treatment services may be beneficial to outcomes. Such facilities provide greater convenience and potentially decreased stigma related to drug treatment, as well as a diminished economic burden for patients, particularly those who live in remote and underserved areas. Evidence indicates that even basic drug interventions like methadone maintenance lead to improved pregnancy and infant outcomes when added to prenatal care (Curet & Hsi, 2002).

Contraceptive Counseling

Sexually transmissible infections (STIs) are a key concern within certain drug using populations, especially those who may trade sex for drugs or engage in other high-risk behaviors that place them at heightened vulnerability (Stahlman, Hargreaves, Sprague, Stangl, & Baral, 2017). Substance-using women report low rates of condom use and high rates of partner change, which places them at high risk of sexually transmissible infections (Lucke & Hall, 2012). Yet, given the low effectiveness of condoms (85%) compared to other methods such as implants (99%) and pills (91%) (Planned Parenthood, 2017) and the serious implications of pregnancy in this group, STI risk can be considered separately from pregnancy risk when counseling substance abusing women on contraceptive methods. United States Medical Eligibility Criteria state that implants, progestin-only pills, and combined hormonal contraceptives may be used without restriction among women at high risk for HIV infection (Tepper, 2017). In some cases, it may be appropriate for contraceptive counseling to encourage addicted women to choose more highly effective methods than condoms and add condoms as a supplementary method if at risk for STIs.

Educational Interventions: Providers and Patients

The first opioid epidemic in the United States was halted through provider education and new methods of dealing with pain and the pain-causing diseases. Therefore, it seems probable that, along with innovations in pain medicine, augmented provider education about opioid prescribing would aid in controlling the unsafe prescribing practices currently in use. Better training is needed around addiction and pain medicine in medical school. In 2014, the Institute for Clinical Systems Improvement released updated guidelines regarding safer opioid prescribing, followed by a 2016 update by the Centers for Disease Control and Prevention. However, evidence suggests that providers are not following these guidelines (Arora, Marcotte, & Hopper, 2017). Other organizations should consider amending their stances on this topic to reflect current evidence, as well.

Further, small community providers may benefit from enhanced training around neonatal abstinence syndrome. Meyer and Phillips (2015) found that community hospitals had significant difficulty in the diagnosis and treatment of neonatal abstinence symptoms. Providers in these locations should be trained adequately to develop expertise in working with the rising numbers of opioid-exposed newborns in remote and rural areas.

Given the poor understanding of addiction, fertility, and the impacts drug use may have on a developing fetus, education for pregnant opioid users is also a paramount concern. Prevention-based efforts to incorporate this information into health and sex education for high school students may be beneficial in reaching students before health crises happen and may prove more easily implemented than conveying information to the hard-to-reach opioid using population. Clearly, providers must take opportunities during appointments with individuals in substance abuse treatment to offer patient education.
Fighting the opioid crisis, opioid use during pregnancy, and NAS also means fighting the stigma surrounding addiction. It may be possible to change detrimental beliefs and misunderstandings about pregnant drug using individuals through an anti-stigma media campaign to adjust how providers and the public view and judge this population, many of whom may be fighting addictions that ensue from untreated medical pain issues, childhood trauma, or other invisible problems. Improved attitudes and acceptance regarding pregnant opioid users might assist in alleviating fears and distrust of the medical establishment within this group, making them more likely to seek prenatal care and drug treatment. Interventions can be designed both for providers and for the public. Greater acceptance by the public may also reduce the effect of “Not in My Backyard” protests against integrated health centers that include drug treatment and methadone clinics. An interesting model for a public-focused anti-stigma intervention has been seen in Baltimore, where in July 2015 the Health Department and partners initiated a public education campaign, ‘Don’t Die’, to educate residents on addiction as a chronic illness and to encourage drug users to pursue treatment (Wen & Warren, 2017). Efforts included a website, social media and billboard ads. The Health Department also educated physicians through letters and an outreach workers campaign to provide information regarding recommended prescribing practices. This type of effort could be sustained in Baltimore and undertaken in other cities, with an added focus on destigmatizing drug users who are pregnant and information on NAS.

Conclusion

The current political landscape and ongoing fight in the United States for funding and access to contraceptives and healthcare in general, along with the poorly managed opioid epidemic, have brought about a troubling situation for pregnant women and newborns affected by drug use. In October 2017, President Trump directed the Department of Health and Human Services (HHS) to declare the opioid crisis a public health emergency, but did not request any funds to address the problem, stating that the government would produce “really tough, really big, really great advertising” to combat the epidemic (Davis, 2017). Trump also donated his third quarter $100,000 salary to HHS, another move seen as merely symbolic by many who hoped the federal government would free up tens of millions of dollars to address the crisis (Cohn, 2017). The danger of these symbolic gestures is that they will serve as placeholders for effective, results-oriented action by a government that merely pays lip service to caring about its voters.

The topic of drug abuse is too widely approached with a focus on law enforcement efforts or on addicts in isolation, as if their families are not also affected by addiction. Addiction affects children and other persons connected to addicted individuals, not just the addicted individuals themselves. The national conversation around opioids must include by-standing victims such as infants with NAS and associated health problems, and more effort should be made to reach opioid-using women at risk of unplanned pregnancy.

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